housing authority of the town of enfield elderly... · housing authority of the town of enfield 1...

HOUSING AUTHORITY OF THE TOWN OF ENFIELD 1 Pearson Way, Enfield, CT 06082

(860) 745-7493 Fax (860) 741-8439

TDD/TTY 800-545-1833 Ext. 849

www.enfieldha.org

Dear Applicant:

The Enfield Housing Authority will be transitioning over to a new system of processing applications.

Applications will receive points ranging from 0-75 based on your documented and verified circumstances.

Preference points will be given for persons living in the following situations:

• condemned or verified serious housing code violations

• inadequate heating, plumbing, or cooking facilities

• living in a documented physically or emotionally abusive situation

• living in a shelter or transitional housing

• living in temporary housing with others because of conditions beyond applicant’s control

(condemnation, foreclosure, fire, loss of job, etc.)

• living in overcrowded conditions in own housing unit

• currently paying more than 31% of income towards rent/housing

Preference points will only be given in situations where the circumstances have been documented and verified.

Should you have any questions regarding this change please contact Diane Stolpinski, State Housing Programs

Coordinator at (860) 745-7493 ext. 211.

The Enfield Housing Authority provides equal opportunity to participate in our housing programs. Any disabled individual requiring a

reasonable accommodation to fully utilize the housing programs and related services may request such by contacting Shari Riddick, Portfolio

Manager, at (860) 745-7493 ext. 202

An Affirmative Action / Equal Opportunity Employer

http://www.enfieldha.org/


(860) 745-7493 Fax (860) 741-8439

TDD/TTY 800-545-1833 Ext. 849

www.enfieldha.org

Applications are accepted in person Monday-Friday (excluding holidays) from 9:00

a.m.-12:00 p.m. or by appointment from 1:00 p.m. - 4:00 p.m., by fax, or via mail.

A COPY OF THE FOLLOWING INFORMATION MUST ACCOMPANY YOUR APPLICATION

COPIES WILL NOT BE MADE AT OUR OFFICE.

1. Verification of income: a. Four current and consecutive pay stubs from your employer, and/or

b. Current statement of gross earnings from Social Security or S.S.I, and/or

c. Current statement of gross earnings from State/City Welfare, and/or

d. Any other household income such as Child Support, Pension, VA

e. Proof of assets (i.e. Current bank statements, assessed value of real estate, etc.)

2. Verification of residency: a. Current month’s rent receipt, or

b. Letter from whom you are currently residing with.

3. Birth Certificates for all family members (long form required for children under 18) a. Physician’s certificate confirming pregnancy (if applicable).

4. Social security cards for all family members

5. Photo identification for all family members 18 and over a. Valid Driver’s license, or

b. Valid State Identification Card

6. All family members 18 and over must sign all areas of the application, complete an Authorization for

Release of Information and CORI form

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

If assistance is needed in completing the application, please contact Diane Stolpinski at 860-745-7493 ext. 211 to

schedule an appointment.

The Enfield Housing Authority has a Smoke-Free Policy



Manager, at (860) 745-7493 ext. 202




(860) 745-7493 Fax (860) 741-8439

TDD/TTY 800-545-1833 Ext. 849

www.enfieldha.org

PROGRAM APPLYING FOR: MODERATE RENTAL FAMILY________ ELDERLY/DISABLED HOUSING________

How did you hear about our housing programs? _____________________________________________________________________

Is head of household or spouse a person with disabilities? YES NO

Please identify any special housing needs your household has:

Are you currently living in a documented physically or emotionally abusive situation? YES NO

Are you currently living in a shelter or transitional housing? YES NO

Are you currently living in temporary housing with others because of conditions beyond your control such as condemnation, foreclosure, fire,

loss of income, etc.? YES NO

How many people live in your current unit? How many bedrooms do you have?

Is your current unit condemned or have verifiable housing code violations? (If yes, please provide documentation in order to qualify for

preference points) YES NO

Does your unit currently have inadequate heating, plumbing, or cooking facilities that can be verified? (If yes, please provide documentation in

order to qualify for preference points) YES NO

Has anyone in your household ever been engaged in the use, sale, manufacture or distribution of controlled substances?

YES NO If yes, when and where?

Has anyone in your household ever been engaged in violent criminal activity?

YES NO If yes, when and where?

Applicant Name: Social Security # DOB SEX Age

______________________________________ ___________________ ____________ M F ______

Last First M.I.

Home Phone ( ) _____________________ Alternate Phone ( )

Marital

Status

Single

Married

Divorced

Widowed

Other

RACE:

White Black American Indian Alaska Native Asian or Pacific Islander

ETHNICITY:

Hispanic ________ Non-Hispanic

Current Address:

Address:

Mailing Address: (If different than above)

Co-Applicant Information: Social Security # DOB Age

___________________________________________ ______________________ _____________ ______

Last First M.I.

Address if different from above City State Zip


HOUSEHOLD MEMBERS: List the names of all household members, applying for housing, below. Start with Head of Household, then

Spouse or Co-Head, then Minors (oldest to youngest) and then any other adults.

Name Sex Relationship

To Head

Social Security

Number

DOB Place of

Birth

School Name or

Occupation

Do you expect anyone to move in or out of your household within the next 12 months? YES NO

If yes, who and when?

Does anyone live with you now who are not listed above? YES NO

If yes, please list full name and relation:

INCOME INFORMATION:

Complete the following for each household member currently employed:

Name Employer Name and

Address

Date of

Employment

Rate of pay Hours per

pay period

Tips/Bonuses

If you or any person in your household receives income from any of the following sources, check the appropriate space and complete the

information below for each member and source of income:

Welfare Assistance/TANF______ Retirement Pension_______ SSI_______ Other_______ Worker Compensation_______

Unemployment VA Benefits_______ Child Support ________ Social Security________ Trust Fund_______

Alimony Armed Forces pay Death Benefit_________ Interest/Dividends_________ Rental Income_______

Received By: Received From: Amount: Occurrence: weekly, monthly, etc.

Did you file a Federal Income Tax return for the most recent year end? YES NO Year: _________

Does anyone outside of your household pay any of your bills or expenses on a regular basis? YES NO

Explain:

Are you or any member of your household self-employed? YES NO

ASSET INFORMATION:

Do you or any member of your household have any of the following assets? YES NO

Checking/Savings account, stocks, bonds, certificates of deposit, money market accounts, trust funds, real estate, retirement funds (IRA,

Keogh,etc), inheritances, lottery winnings, life insurance policy, insurance/judicial settlement, investment accounts, etc.

If yes, please complete the information below for each household member and asset type:

Name Asset Type Market/Cash Value Income earned Joint/Individual

Does any member of your household own any real estate? YES NO

If yes: Where Market Value

BANKING INFORMATION

Name of Bank Type of Account Balance

Have you or any other member of your household ever lived in public housing? YES NO

If yes, explain: When: Where:

Have you or any other adult member of your household ever used any name(s) or Social Security number(s) other than the one you

are currently using? YES NO If yes, explain

Have you or anyone in your household ever been convicted of any crime other than minor traffic violations?

YES NO If yes, explain:

Have you ever committed fraud in any assisted housing program or been requested to repay money for knowingly misrepresenting

information for such housing programs? YES NO

If yes, explain:

I/We certify that the information given to the Enfield Housing Authority including, but not limited to, household composition, income, assets,

allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that giving false statements

or information can be grounds for automatic denial of my/our application. I/We understand that this is not a contract and does not bind either

party.

I understand that in the event I change addresses, phone numbers, family size or income, it is my responsibility to notify Enfield Housing

Authority in writing. Failure to notify any of these changes could result in cancellation of my application.

I/We understand that this application will be processed and reviewed in accordance with the Enfield Housing Authority’s Admissions and

Continued Occupancy Policy along with any applicable Federal, State and local laws and regulations.

Signature of Head of Household Printed Name Date

Signature of Spouse/Co-Head of Household Printed Name Date

Signature of Other Adult Household Member Printed Name Date


Verification of Credit History

RELEASE:

As part of applying for Housing, I/We, do represent all information in this application to be true and accurate and that the Enfield Housing

Authority may rely on this information when processing this application. Applicants hereby authorize the Enfield Housing Authority to make

independent investigations to determine my credit, financial and character standing. Applicant(s) authorizes any person, or credit checking

agency having any information on him/her to release any and all such information to the Enfield Housing Authority or credit checking agencies.

Applicant hereby releases, remises and forever discharges, from any and whatsoever, in law and equity, the Enfield Housing Authority, both of

Landlord and their credit checking this application, and will hold to harmless from any suit or reprisal whatsoever. I understand that the credit

report (rental history, arrest and/or conviction records and retail credit history) will be done through the facilities of the Info Center, Inc.,

Feeding Hills, MA 01030, Consumer Phone 413-562-5650.

Applicant: ________________________________________ SSN: ________________________ DOB: _______________________

Address: ____________________________________________________________________________________________________

Co-Applicant: ____________________________________ SSN: _________________________ DOB: ______________________

Address: ______________________________________________________________________________________________________

Please list all landlords for the past three (3) years:

Applicant Current Address: _____________________________________________________________________________________

Landlord Name: ________________________________________________________________________________________________

Landlord Address: ______________________________________________________________________________________________

Phone Number: ________________________________________ Dates Resided: ____________________ to ____________________

Previous Address: ______________________________________________________________________________________________

Previous Landlord Name: _________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

Phone Number: _______________________________________ Dates Resided: ____________________ to _____________________

Co-Applicant (if different from above)

Current Address: ______________________________________________________________________________________________

Landlord Name: ________________________________________________________________________________________________

Landlord Address: ______________________________________________________________________________________________

Phone Number: ______________________________________ Dates Resided: ______________________ to ____________________

Previous Address: _______________________________________________________________________________________________

Previous Landlord Name: _________________________________________________________________________________________

Address: ______________________________________________________________________________________________________

Phone Number: _____________________________________ Dates Resided: ______________________ to _____________________

____________________________________________________ ___________________________________________________

Applicant Signature Co-Applicant Signature


Verification of Rental History

The person mentioned below has applied for residency with the Enfield Housing Authority and has indicated that you

now have or previously had this family/individual as a tenant at your property.

As indicated by the person’s signature, he/she consents to the release of information pertaining to rental history at the

address mentioned below.

Applicant’s Authorization: ___________________________________________________________________

(please sign)

(APPLICANT PLEASE DO NOT FILL IN SECTION BELOW)

RE: ___________________________________________________________________________________

Address: __________________________________________________________________________________

Please answer the following questions regarding the tenant’s rental history.

1) Move in date: _____________ Move out date: _____________

2) How many bedrooms? ________________________ Number of occupants? _________________________

3) What is/was the monthly rent? _____________________ Are/were payments made on time? __________________

If the tenant paid late, how often? _______________ How many days late? _________________________

4) Are/were utilities included in the rent? Yes No

If no, what utilities is/was the tenant responsible for? _______________________________________________

5) Did the tenant leave owing a balance? Yes No

6) Is this unit a subsidized or public housing unit? Yes No

7) What types of damage, if any, has the tenant caused in the unit or in the common property? ________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

8) Has any action ever been taken against the tenant for disturbing other tenants or controlling the behavior of their

children and/or guests? If so what type of action and how many times?

________________________________________________________________________________________________________

________________________________________________________________________________________________________

9) Did the tenant ever have anyone other than those named on the lease residing in the unit? Yes No

10) Did you ever begin eviction proceedings? Yes No

If yes, what was the reason? _______________________________________________________________

______________________________________________________________________________________

11) Are you a family member or friend of the tenant? Yes No

If yes, what is the relation? _________________________________________________________________

12) If the tenant moved and re-applied for housing in the future, would you rent to him/her again? ______________

If not, why? ____________________________________________________________________________________________

Additional Comments: __________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

______________________________________ ____________________________________

Landlord Signature Printed Name

______________________________________ ____________________________________

Title Date



(860) 745-7493 Fax (860) 741-8439

TDD/TTY 800-545-1833 Ext. 849

www.enfieldha.org

Authorization for Release of Information

I, (print name) ________________________________________, authorize the Housing

Authority of the Town of Enfield, or its agents, to access any and all Local, State, and/or

Federal Criminal records pertaining to me for the housing application screening process.

_____________________________ _______________________

Signature Date

______________________________ ________________________

Date of Birth Social Security Number



Manager at (860) 745-7493 ext. 202



Enfield Housing Authority

1 Pearson Way

Enfield, CT 06082


(860) 745-7493 Fax (860) 741-8439

TDD/TTY 800-545-1833 Ext. 849

www.enfieldha.org

DEMOGRAPHICS SURVEY

Under Section 8-37ee-313, paragraph b, of the Connecticut General Statutes, we are required to perform a

demographic survey of all housing applicants as well as residents. At this time, I would like to ask that you complete

the information below and return the form to the Enfield Housing Authority office with your application. This data

will be kept confidential and will only be used as required by the State of Connecticut for Fair Housing reporting.

PLEASE PROVIDE THE FOLLOWING INFORMATION:

Address: _________________________________________________________________________

*Below please indicate the number of persons of each race in your household:

Race: ________ Caucasian ________ Black or African American ________ Asian

________ Hispanic or Latino ________ American Indian, Alaska Native, Native Hawaiian, other

Pacific Islander, or Other

Family Composition:

______ Adults (how many currently reside in the household)

______ Children (how many currently reside in the household)



Manager, at (860) 745-7493 ext. 202



CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER,

SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.

The Enfield Housing Authority is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the

purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license

applicants, current licensees, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the

rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the

DCJIS. I hereby acknowledge and provide permission to the Enfield Housing Authority to submit a CORI check for

my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw

this authorization at any time by providing the Enfield Housing Authority written notice of my intent to withdraw

consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:

The Enfield Housing Authority may conduct subsequent CORI checks within one year of the date this form was

signed by me provided, however, that the Enfield Housing Authority must first provide me with written notice of this

check.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2

of this Acknowledgement Form is true and accurate.

___________________________________ ______________________________

SIGNATURE DATE

1 OF 2

SUBJECT INFORMATION: (A red asterisk (*) denotes a required field)

______________________________________________________________________________

*Last Name *First Name Middle Name Suffix

_____________________________________________________

Maiden Name (or other name(s) by which you have been known)

________________ ________________________________

*Date of Birth Place of Birth

*Last Six Digits of Your Social Security Number: _______-_________

Sex: ____ Height: ___ft. __ in. Eye Color: _________ Race: __________

Driver’s License or ID Number: _____________________ State of Issue: ___________

____________________________________ ___________________________________

Mother’s Full Maiden Name Father’s Full Name

Current and Former Addresses:

______________________________________________________________________________

Street Number & Name City/Town State Zip

______________________________________________________________________________

Street Number & Name City/Town State Zip

The above information was verified by reviewing the following form(s) of government-issued

identification:

_______________________________________________________

_______________________________________________________

VERIFIED BY: ____________________________________________________

Name of Verifying Employee (Please Print)

________________________________________________

Signature of Verifying Employee

2 OF 2

DECLARATION OF SECTION 214 STATUS

I, _____________________________________________________, certify, under penalty of perjury 1/, that, to the

best of my knowledge, I am lawfully within the United States because (please check the appropriate box):

□ I am a citizen by birth, a naturalized citizen or a national of the United States; or

□ I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age 2/; or

□ I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach

INS document(s) evidencing eligible immigration status and signed verification consent form.

□ Immigrant status under §§101(a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA) 3/;

or

□ Permanent residence under §249 of INA 4/; or

□ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of the INA 5/; or

□ Parole status under §§212(d)(5) of the INA 6/; or

□ Threat to life or freedom under §243(h) of the INA 7/; or

□ Amnesty under §245A of the INA 8/.

By signing this form, I am allowing permission for the requesting agency to verify the information stated above.

________________________________________________ ________________________

(Signature of Family Member) (Date)

□ Check box on left if signature is of adult residing in the unit who is responsible for child named on statement

above.

(See reverse side for footnotes and instructions)

Enter INS/SAVE Primary Verification #___________________Date:_____________

Notice to applicants and tenants: In order to be eligible to receive the housing

assistance sought, each applicant for, or recipient of, housing assistance must be

lawfully within the U.S. Please read the Declaration statement carefully and sign

and return to the Housing Authority’s Admissions Office. Please feel free to

consult with an immigration lawyer or other immigration expert of your choosing.

1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a

document containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any

department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five

years, or both.

The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following

categories:

2/ Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older

or who will be 62 years of age of older and receiving assistance under a Section 214 covered program on June

19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence

of proof of age. No further documentation of eligible immigration status is required.

3/ Immigrant status under §§101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted for permanent

residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as

defined by §101(a)(15) of the INA (8 U.S.C.1101(a)(20) and 1101(a)(15), respectively [immigrant status].

This category includes a noncitizen admitted under §§210 or 210A of the INA (8 U.S.C. 1160 or 1161),

[special agricultural worker status], who has been granted lawful temporary resident status.

4/ Permanent residence under §249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or

such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who

is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result

of an exercise of discretion by the Attorney General under §249 of INA (8 U.S.C. 1259) [amnesty granted

under INA 249].

5/ Refugee, asylum, or conditional entry status under §§207. 208 or 203 of INA. A noncitizen who is

lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status];

pursuant to the granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158)

[asylum status]; or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C.

1153(a)(7)) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or

political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].

6/ Parole status under §212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an

exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public

interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].

7/ Threat to life or freedom under §243(h) of INA. A noncitizen who is lawfully present in the U.S. as a result

of the Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [threat to life

or freedom].

8/ Amnesty under §245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under

§245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A].

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